Dose Reduction to the Swallowing Apparatus and the Salivary Glands by De-Intensification of Postoperative Radiotherapy in Patients with Head and Neck Cancer: First (Treatment Planning) Results of the Prospective Multicenter DIREKHT Trial

Marlen Haderlein, Stefan Speer, Oliver Ott, Sebastian Lettmaier, Markus Hecht, Sabine Semrau, Benjamin Frey, Claudia Scherl, Heinrich Iro, Marco Kesting, Rainer Fietkau, Marlen Haderlein, Stefan Speer, Oliver Ott, Sebastian Lettmaier, Markus Hecht, Sabine Semrau, Benjamin Frey, Claudia Scherl, Heinrich Iro, Marco Kesting, Rainer Fietkau

Abstract

Aim: Evaluating radiotherapy treatment plans of the prospective DIREKHT trial (ClinicalTrials.gov, NCT02528955) investigating de-intensification of radiotherapy in patients with head and neck cancer.

Patients and methods: The first 30 patients from the DIREKHT trial of the leading study centre were included in this analysis. Standard treatment plans and study treatment plans derived from the protocol were calculated for each patient. Sizes of planning target volumes (PTVs) and mean doses to organs at risk were compared using the Student's t-test with paired samples.

Results: Mean PTV3 including primary tumor region and ipsilateral elective neck up to a dose of 50 Gy in the study treatment plans was 662 mL (+/- 165 mL standard deviation (SD)) and therefore significantly smaller than those of the standard treatment plans (1166 mL (+/- 266 mL SD). In the medial and inferior constrictor muscles, cricopharyngeal muscle, glottic and supraglottic laryngeal areas, arytenoid cartilages, contralateral major salivary glands highly significant dose reductions (p < 0.0001) of more than 10 Gy were achieved in study treatment plan compared to standard treatment plan.

Conclusion: De-intensification of radiotherapy led to smaller planning target volumes and clinical relevant dose reductions in the swallowing apparatus and in the contralateral salivary glands.

Keywords: de-intensification; head neck cancer; ipsilateral elective neck irradiation only; postoperative; radiotherapy; salivary glands; swallowing apparatus.

Conflict of interest statement

On behalf of all authors the corresponding author states that there is no conflict of interest.

Figures

Figure 1
Figure 1
Flow Chart of the DIREKHT trial.
Figure 2
Figure 2
Planning target volume 3 (PTV3) of study treatment plan compared to standard treatment plan.
Figure 3
Figure 3
Male patient with a HPV-associated tonsillar carcinoma on the right side; TNM according to 7th edition of TNM classification: pT1pN2b (3/29 without ECS) L0 V0 Pn0 R0 cM0. According to study protocol this patient was treated with a reduced radiotherapy dose of 56 Gy in the primary tumor region only with ipsilateral elective neck irradiation. In the standard treatment plan, the patient would have received a total dose of 64 Gy in the primary tumor region and bilateral elective neck irradiation. (a) Dose distribution of the standard and study treatment plan (blue contour within the high-dose-volume is the boost which is additionally applied in the standard but not in the study treatment plan) with the study treatment plan showing especially significant reduced dose in contralateral neck and pharyngeal structures. In the study treatment plan most parts of the swallowing structures receive less than 30% of the prescribed dose while in the standard treatment plan large parts of the swallowing apparatus receive 40 to 60% of prescribed dose. (b) Dose-volume histogram of superior (light green), medial (orange), inferior (blue) constrictor muscle and cervical esophagus (pink) shows significantly smaller doses in constrictor muscles and cervical esophagus in the study (solid line) compared to the standard (dotted line) treatment plan.

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